I need feedback from dialysis nurses.

RainDreamer, BSN, RN · Sep 20, 2005

Hi and welcome to allnurses!! :)

**RosesrReder, BSN, MSN, RN** · Sep 20, 2005

hello and welcome to the wonderful family of allnurses.com. enjoy your stay, and best of luck to you. :)

chatty-rn · Sep 21, 2005

The medical director of our dialysis center accepted a new pt last week who requires much care from our staff. This pt is unresponsive, quadraplegic, hx cva, brain damage, trach (need sx several times on tx), sacral decub with wound drain, and often has bm on hd, tx time 4 1/2 hrs. It takes at least 3 staff members to clean and change pt when this occurs, which leaves only 1 staff member to monitor the others pts on tx. I am curious as to how other dialysis facilities handle pts and situations such as this. Thanks.

Hi, this is hard, I've had pts like this too. Is the family involved? Maybe a care conference with the family, doctor, social worker and nurse would be beneficial. Any advance directives? People seem to think dialysis can help everything be better. good luck

nosonew, BSN, RN · Oct 1, 2005

Honestly? QUALITY OF LIVE VS. QUANTITY OF LIFE in question here. If the prognosis WITH dialysis treatment is POSITIVE.. YEA! If not... BOO!

And honestly, you have to respect the rights and decisions of the family, however, find out if there was ever a living will, and perhaps even discuss with the family about DNR issues.

Actually, besides staffing issues, I see a bigger issue with what the other patients see. How depressing for them. How does it effect the REST of your patients? Is there an isolation room this patient can go to for 1-1 care? Is there a rehab facility that offers dialysis for post-cva patients? How old is the patient?

What is the family like? Are they doing this per patient wishes or their own?

YOu need to really get to know this family... I mean GET TO KNOW them...

Good luck.. by getting in THEIR heads, perhaps you can figure out the interpersonal issues occurring. :crying2:

Also, discuss during your next staff meeting WHY the patient was accepted. If you are at a for profit agency... why? If non-for-profit, WHY? Either/Or... why?

Most of the nephrologists I know would DISCOURAGE dialysis for a patient like this.

KAT1994 · Oct 1, 2005

Dialysis becomes very hard when you feel like you are doing it to the pt instead of for the pt.

When our unit has a heavy care pt like this one we usually require a caregiver to come with the pt. The pt sounds like one that would have a full time caregiver. Is he from a nursing home? We also have mobile screens we can put up for privacy.

At our unit we also do not allow any dialysis in beds. If a pt is not stable enough to dialyze in a dialysis chair, then they most likely are not stable enough for the staffing ratio of a chronic unit.

Does your Center Director have any concern for infection control if the staff is cleaning up stools, resp. sx, any uncontained wound drainage? Chances are this pt is colonized with very resistant bacteria. For the other pts, I hope the CD has taken steps to control infection in the unit.

jnette, ASN, EMT-I · Oct 2, 2005

Does your Center Director have any concern for infection control if the staff is cleaning up stools, resp. sx, any uncontained wound drainage? Chances are this pt is colonized with very resistant bacteria. For the other pts, I hope the CD has taken steps to control infection in the unit.

Wow.

I agree with the above. We have one lady who is too obese to walk, and comes in via stretcher. We have purchased an oversized dialysis chair for her, but very occasionally she will need to have a bm. This is a huge concern re infection control. Our Clinincal Mgr. is reluctant to keep the patient at our facility.. or ANY outpatient facility due to this concern.

We deal with other patients' blood and accesses.. we should NOT be dealing with feces at the same time in the same place. Regardless of handwashing, the risks are too great.

Your patient should never have been accepted at an outpatient setting. I am truly shocked that he was.

There are many available inpatient rehab facilities which provide dialysis.

We, too, do not accept patients who are unable to sit in a chair, or who are of such high acuity. This is absurd to expect the staff to provide all the care this patient will need.. not to mention how depressing this must be to your other patients.

Truly, I am beyond words that this patient was accepted by your Medical Director.

If it MUST be, ie. no other options available, then yes.. but ONLY if a caregiver is with the patient at all times. This one on one care is NOT the responsibility of your staff. God knows they have enough to do as it is. :uhoh3:

Our Medical Director would not have accepted this patient.

I fully agree..quality, not quantity of life. But it should be the patient's choice.

IS this the patient's wish?

How tragic.

renerian, BSN, RN · Oct 2, 2005

I understand the patient needs care but would another place to have it done be an option?

Two thoughts. If it is in a unit with patients that walk, talk and are not that ill, I would probably not feel "uh encouraged" to see someone like that next to me. I know it would frighten some.

Second, I would worry about cross contamination in all the wound care you would either be doing, be exposed to, or other contaminates such as MRSA might creep onto the unit.

renerian

babs_rn · Oct 2, 2005

Are you in Florida? This sounds exactly like a patient we recently refused. Thank GOD. The nursing home they were going to send her to was uncomfortable with it, as the CD I was uncomfortable with it, and the doc's liason was uncomfortable with it. Bottom line (that we went with) was that if she needed constant or even just frequent suctioning there was no way she was going to get it en route between the center and the nursing home. Non-emergency transport can't do that, and EMS can't reliably deliver and pick up a patient on time because they have real emergencies - not to mention the act of Congress it takes to be able to get them reimbursed. So we refused on the basis of patient safety.

I firmly hold to the belief that we are not set up for acute nor for custodial care. Patients like that need to be in a rehab hospital or - more mercifully - in hospice. But the families are what they are, and a little knowledge can be a dangerous thing. However, I do see a disturbing growth in what I call the "grey area" - patients who are too sick or incapable of caring for their basic needs and yet do not qualify for custodial care. We dialyze them to keep them breathing but quality of life is nil. It's a sad state we're in, and I firmly believe that just because you can do something doesn't always mean you should - but what can you do? Legal issues being what they are - look at the Schiavo case. It's a quagmire.

I also firmly believe that as we have patients of higher acuities coming into the outpatient centers to dialyze eventually the dialysis companies are going to have to be forced to have facilities available TO bathe and change patients and may have to (one day) look at acuity-based staffing. There's a nightmare. The other option is to refuse these patients once CMS starts reimbursing based on outcome scoring because these are the ones who will bring your score down. Fun times ahead, I tell ya.

jnette, ASN, EMT-I · Oct 2, 2005

Are you in Florida? This sounds exactly like a patient we recently refused. Thank GOD. The nursing home they were going to send her to was uncomfortable with it, as the CD I was uncomfortable with it, and the doc's liason was uncomfortable with it. Bottom line (that we went with) was that if she needed constant or even just frequent suctioning there was no way she was going to get it en route between the center and the nursing home. Non-emergency transport can't do that, and EMS can't reliably deliver and pick up a patient on time because they have real emergencies - not to mention the act of Congress it takes to be able to get them reimbursed. So we refused on the basis of patient safety.
I firmly hold to the belief that we are not set up for acute nor for custodial care. Patients like that need to be in a rehab hospital or - more mercifully - in hospice. But the families are what they are, and a little knowledge can be a dangerous thing. However, I do see a disturbing growth in what I call the "grey area" - patients who are too sick or incapable of caring for their basic needs and yet do not qualify for custodial care. We dialyze them to keep them breathing but quality of life is nil. It's a sad state we're in, and I firmly believe that just because you can do something doesn't always mean you should - but what can you do? Legal issues being what they are - look at the Schiavo case. It's a quagmire.
I also firmly believe that as we have patients of higher acuities coming into the outpatient centers to dialyze eventually the dialysis companies are going to have to be forced to have facilities available TO bathe and change patients and may have to (one day) look at acuity-based staffing. There's a nightmare. The other option is to refuse these patients once CMS starts reimbursing based on outcome scoring because these are the ones who will bring your score down. Fun times ahead, I tell ya.

Excellent post, Babs. I agree 100%.

Our patients of late have had higher acuity as well.. much higher than in previous years. But we have to draw the line somewhere. We simply are not set up to care for theses high acuity patients, nor do we have the staff to care for their many needs.

I would think the dialysis industry would look into placing more units in inpatient rehab facilities where these patients can be dialyzed without having to travel or jeopardize their health enroute... transportation is a real problem, as you already stated.

Yes, the outcome scoring is going to be a real challenge. It's going to be interesting. :uhoh3:

babs_rn · Oct 2, 2005

That decub is another issue altogether. When contaminated with BM, that dressing has to come off and be replaced. Dialysis centers do not typically have that kind of wound dressing available and many companies have strict policies against changing or manipulating a wound dressing on the treatment floor (dialysis catheter dressings aside). And where else do you have to do all this? Maybe an exam room if you're lucky? Iso won't cut it because that's Hep B iso. And you might have patients running in there. Even if you don't at the moment, if you have an Iso patient who runs at all you can't use that. Yet you can't just leave a patient sitting in their own BM. Grey, grey, grey, grey, grey. It's challenging enough keeping patients turned and positioned in those chairs that are already so quick to contribute to a pressure ulcer in a compromised patient.

tizmonster · Nov 23, 2005

I am aware that a number of the groups are developing dialysis suites in long term care facilities./rehab. The advantage to the patient is they aren't encumbered with being moved, and the staff to patient ratio is usually 2-1 . The other issue is as the patient population is exploding - this enables those ambulatory patients to utilize chronic facilities. The quality of care for the patient is much better in this setting. It's just a better approach for the care givers and those receiving the care.